When Hierarchy Reigns, Culture Change Efforts Flounder

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We can create homey spaces, offer elders more choice and change long standing institutional practices, but culture change and the Household Model will not be effective unless we flatten the organization. As long as hierarchy reigns, elders will not be in control of their own lives. And as long as departmental silos dictate the way things are done, staff closest to elders will not be able to do what they can to help elders live a meaningful life in a place that truly feels like home. A nursing home can have a warm appearance, a friendly atmosphere, do fun and interesting things with its residents, but unless the decisions of daily life are made by elders and those closest to them, the culture is still one of one-size-fits-all-this-is-just-the-way-it’s-done.

Elders can’t make choices in the moment when what they want needs to be OK’d by three different people, one or two of whom may not even know them. One of the things we all enjoy about being in our own homes as opposed to work, a hotel or even at a friend or family member’s home, is the freedom to make spontaneous decisions, to have things the way we like them and go about our day according to our own schedule.  A household or neighborhood team comprised of staff from all disciplines that makes decisions together and is responsible to one another can most effectively meet elders needs. Cross-training and versatile workers within the team allow more people within the team to respond to the elder in front of them instead of having to go find someone else who can do the job. It can also be a great benefit at the busiest times of the day when extra help is needed in one particular area.

Only when the household or neighborhood teams have the responsibility, authority and flexibility to make decisions can they reach their full potential for giving individualized care and creating true home for the elders they serve.

The process of flattening the organization is not something that is done overnight. I suggest 3 steps to move forward with this process.

  1. Make your organization one of Shared Leadership.
  2. Use Learning Circles to help staff communicate.
  3. Create an environment of High Involvement.

We will go into more detail about each of these steps in upcoming blog posts. Please share your own challenges and successes in flattening the organization in the comment section.

LaVrene Norton is the founder of Action Pact, an organization devoted to changing the culture of care environments for elders – making it possible to live in a homey place & have a good day every day, no matter how frail one becomes.  Action Pact has assisted care organizations on their journey to households since 1997. Norton is co-author with Steve Shields of In Pursuit of the Sunbeam, and publisher of a variety of educational books, workbooks and videos focusing on the Household Model.

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3 thoughts on “When Hierarchy Reigns, Culture Change Efforts Flounder

  1. Yes, I saw the result of these “silos” in my mother’s nursing home when she passed very recently. She was supposed to be palliative care only, no hospitalization, but the night nurse on her wing sent her to the hospital without my permission in the middle of the night. That began a rapid decline over 3 days, during which I was at my mother’s side and trying my best (with hospice only an hour a day) to make sure Mom received the care she needed. It was traumatic for all. Something went very wrong with the internal communication in the nursing home, and after this early period of grief and anger I will try to figure it out. This was an example of the “culture of care” not working. Mom suffered more than she needed to.
    –Martha Stettinius, author, “Inside the Dementia Epidemic: A Daughter’s Memoir” http://www.insidedementia.com

    • I’m sorry that your mother had such a difficult time. Restructuring the organization into staff teams dedicated to each household results in two important strengths – staff knows the residents and their families better than in the traditional nursing home you described – and they have the opportunity to develop critical thinking skills as they grow in their
      knowledge of each resident. You are doing good work in her name. She would be proud.

  2. This post hits at the heart of transformative culturre change. Every word of the entire first paragraph must make its way deep into the heart of leaders who want “culture change” if real transformation is to take place. I have heard stories of administrators who attend a conference, get excited by the ideas they hear and then go home to make changes: they quit using “clothing protectors” and go to “dining scarves.” But every resident is still automatically expected to wear them. The administrator hears about neighborhoods with names and so goes back to the workplace and tells the residents to choose a name for their end of the long institutionally-built-and-run hallway.

    Untill the traditional understanding and exercise of leadership is turned on its head, these ‘innovations’ will be mere appendages to a continuing sterile, schedule-run warehouse of elders who have lost themselves — or rather — who have been made lost by the system and by unprepared persons in precious positions of leadership.

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